Denis O'Donovan (Fianna Fail)
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I welcome the Minister of State and call on Senator Mary Ann O'Brien to move the motion. The Senator has ten minutes. I understand Senator Averil Power will second the motion.

Mary Ann O'Brien (Independent)
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I move:

“That Seanad Éireann:

notes The Case for Change report published by the Asthma Society of Ireland in February 2014, which included commentary on the prevalence and seriousness of asthma in Ireland; and

acknowledges that:- there are very significant numbers of people in Ireland living with asthma;

- hospital admissions from asthma are considered avoidable; recent OECD statistics show that the rate of admission in Ireland is slightly below the OECD average;

- through a combination of the means-tested medical and GP card schemes and the phased roll-out of universal GP care, more people than ever before (over 2.1 million people) have access to a GP service without fees, including those families facing undue financial burdens and the youngest and oldest in society;

- medical card holders are entitled to prescription medicines free of charge, subject to prescription charges capped at €25 per month per person or family;

- under the drugs payment scheme, no individual or family pays more than €144 per month towards the cost of approved prescribed medicines, which significantly reduces the cost burden for families and individuals incurring ongoing expenditure on medicines;

- significant progress has been made by the HSE in the development of the national clinical programme for asthma:

- the programme has focused on the development of national asthma guidelines based on international best practice, both for acute care and ongoing asthma management;

- emergency asthma guidelines for adults and emergency paediatric asthma guidelines have been published;

- the emergency asthma guidelines for adults are currently being considered by the national clinical effectiveness committee and, once approved, will be formally launched;

- guidelines for managing a patient with asthma in primary care have been approved by the Irish College of General Practitioners and were launched in May 2013;

- the model of care for asthma has been approved by the HSE and is due to be launched in the coming months. The model of care details how physicians, nurses, and other health care professionals will work with engaged patients to make the most appropriate clinical decisions and to collaborate with specialist colleagues in providing a safe, seamless patient experience within the health system in Ireland;

- easily accessible patient asthma education supports have been developed in conjunction with the Asthma Society of Ireland to assist guided self-management;

- the community-based asthma integrated care demonstrator project is scheduled to commence by the end of 2015; and

- proposals for an audit of asthma deaths are being developed and will be expedited;

- on 1st July 2015, GP care without fees at the point of access was introduced for children under six years, providing an enhanced service that includes an agreed cycle of care for children diagnosed with asthma;

- negotiations are under way on a comprehensive new GP contract, a priority of which is the inclusion of chronic disease management, including asthma; and

- the Government is committed to the extension of free GP services to all children under 12 years of age, subject to negotiations in relation to the scope of the service to be provided and the fee arrangements to apply.”

I welcome the Minister of State. I also welcome Sharon Cosgrove, chief executive officer of the Asthma Society of Ireland. The two asthma sufferers with her are a little like Coca-Cola; they are the real thing. They are Rebecca Fitzsimons and Catriona Kennedy. I welcome them and thank them for coming to the Gallery this evening.

We are here to discuss asthma, which, believe it or not, directly affects 470,000 people in Ireland. When I was approached by the Asthma Society of Ireland to table this motion, I quickly discovered that I had little knowledge of the prevalence of asthma in Ireland and the debilitating effect it can have on those with the condition.

What is asthma? Asthma is a condition that affects the airways, the small tubes that carry air in and out of the lungs. The airways become oversensitive which means they react to things that would normally not cause a problem, such as cold air or dust. This reaction causes muscles within the wall of the airways to tighten and become narrow, thereby making difficult for the air to flow in and out. The lining of the airways becomes swollen and sticky mucus is produced clogging up the breathing passage. I have talked to some sufferers in preparation for this evening. It is difficult for us to imagine. It is somewhat like breathing through a tiny straw and being absolutely terrified while the chest is hurting at the same time. It feels like one is fighting for one's life.

I wish to read some statistics into the record this afternoon in order to help us to keep our conversation in perspective. Ireland has the fourth highest prevalence of asthma in the world. In itself, the reason for that deserves to be a research project. One adult in ten has asthma while one child in five has the condition. Some 60% of people in Ireland have uncontrolled asthma, meaning they are at risk of an asthma attack. Every 26 minutes someone visits an accident and emergency unit because of asthma. More than one person every week dies in Ireland from asthma, although 90% of asthma deaths are preventable. The economic burden of asthma is estimated to be €500 million per year. Adults miss an average of 12 days of work each year due to asthma and children miss an average of ten days in school due to asthma. On average, asthma patients spend €150 per month on medication and they can spend up to €450 per year on general practitioner visits.

The information I have set out is rather stark. My motivation in tabling the motion - and that of the Asthma Society of Ireland in encouraging me to do so - is to draw attention to the serious challenges that asthma presents to us as policy makers. More importantly, it highlights the effects and burden that asthma places on those unlucky enough to have the disease.

The Asthma Society of Ireland was keen for me to acknowledge the Minister of State's positive engagement with it since she took up her position in the Department of Health. In particular, the society referenced her most recent meeting with its representatives prior to the introduction of the budget in October.

We should reference the inclusion of the asthma cycle of care in the general practitioner contract relating to those under six years of age and the intention of the Minister of State to include that in the finalised contract relating to under 12s. Furthermore, we should reference that the HSE is looking favourably on, and is engaged with, a proposal to fund the Asthma Society of Ireland asthma advice line next year for the first time. This is a vital free resource for those with asthma in Ireland. I hope the talks will conclude positively in the coming weeks. I welcome the recent announcement by the Minister of State that the society would receive €45,000 in nationally lottery moneys to help fund the inhaler technique campaign which the society ran earlier this year throughout the country. However, despite these positive actions and the signs of future actions, many grave problems still exist for people in Ireland who are living with asthma. I will outline some of these for the consideration and response of the Minister of State. I know my colleague, Senator Power, will have a unique perspective on this topic as, unfortunately, she is asthmatic. As with most situations in life, those who have walked in the shoes have the best understanding of the problems and challenges encountered on a daily basis.

As the Minister of State will appreciate from the time she has spent in the Department of Health and in politics in general, most of the time people clamour to highlight problems but few come to the table with suggested solutions. I am not for a moment suggesting that this is what I am doing; I am merely going to point the House in the direction of the HSE national clinical programme for asthma, NCPA, which was agreed in 2011 following extensive consultation with all stakeholders. Much to the frustration of the asthma society and its members, implementation has been slow, at best. I note that the NCPA has developed a large range of guidelines. However, I imagine even the Minister of State would acknowledge that implementation of the programme has not been seen, in particular, in primary care settings. While this programme was developed before the period of the Minister of State in office, I am keen for her thoughts on why full implementation has been so slow. I find it somewhat puzzling given that the HSE signed off on the plan. Why has delivery been so difficult? Has the Minister of State encountered opposition from the medical bodies or has the issue become lost in the broader health reform programme?

In its simplest form, the NCPA means that everyone with asthma in Ireland can avail of structured best-practice asthma care in their community. Having read up on the programme it seems to me to draw on international best practice and learnings. For the want of a better description, it presents the motorway to transforming the experiences of people with asthma in Ireland. Interestingly, it should result in financial savings for the health service. I call on the Minister of State to set out the achievements to date with the NCPA and outline her vision for its implementation in the period ahead. I know the asthma society and those gathered in the Gallery are keen for the Minister of State to share her opinions on the following potential actions: the introduction of a scheme to assist people with asthma with the financial burden of their disease - a point Senator Power will illustrate in few moments; the delivery of a free annual asthma review for each person with asthma, as recommended in the HSE national clinical programme for asthma - this is crucial for a good asthma management; and, as per the national clinical programme for asthma, the undertaking of an asthma deaths study nationwide. As a country, this is something we must address as soon as possible. I await the contribution of the Minister of State with interest.

Averil Power (Independent)
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I second the motion.

I thank my Independent colleague, Senator Mary Ann O'Brien, for tabling this important motion. The statistics she read into the record are stark indeed. Two figures struck me in particular. First, every 26 minutes someone visits an accident and emergency department due to asthma. Second, someone dies every week because of asthma, yet 90% of these deaths are preventable. That is frightening. It means that every year we have approximately 50 people dying but 45 of them need not have died. It is a great loss to their families and a sad indictment of our position in respect of this chronic condition.

Asthma is a manageable condition. With the right medication and proper management procedures there is no reason why someone should end up having an acute attack, let alone end up in an accident and emergency department or with fatal consequences.Many successful athletes have asthma, including David Beckham, Ronan O'Gara and many GAA stars. The Asthma Society of Ireland has worked with GAA stars to promote awareness of the fact that having asthma does not mean a person cannot exercise. Even if one has exercise-induced asthma, there are ways of controlling it to enable exercise and help one to stay fit and look after one's health. Having asthma does not need to hold people back and yet, as Senator Mary Ann O'Brien has said, 60% of people who have asthma do not have their condition under control. I believe there are two main reasons for that. One reason is under-developed primary care and a lack of education, and another reason is the cost of medication.

With regard to education, many asthma sufferers simply do know how to handle their condition properly using breathing techniques and in other ways that do not necessarily involve medication but that need to be taught. I welcome the emphasis on asthma management under the programme of free GP care for children under six years of age, and I think it is good to start with young people. Many people develop asthma while in their teens, so there is a need to help in that age group also. I developed asthma in my teens. I had my first asthma attack at a PE class in school. I had no idea what was wrong with me. All I knew was that I could not breathe and it was incredibly frightening. A girl in my class handed me an inhaler and told me to take it. I wondered what it was, but it worked. I understand there are problems in some schools around the sharing of medication. There is much bureaucracy and fear about taking medicines while in school and the possibility of someone taking the wrong medicine. If that classmate had not handed me the inhaler I do not know what state I would have ended up in.

The cost of medication is the other big issue for people. Asthma medication in shockingly expensive in Ireland. I take a preventative inhaler called Seretide, which works extraordinarily well. I exercise: I box, I run and I do all kinds of sport. I can run on a treadmill for 20 to 30 minutes without taking any reliever inhaler because my preventative inhaler is so good. However, it costs €80 per month. When I was in college I could not afford it. On four or five occasions while I was in college I ended up in the accident and emergency department on nebulisers and had to stay in hospital overnight with frightening asthma attacks because I could not afford the inhaler. There are costs to the health service because of that, let alone the cost to the individual of that frightening experience. There is a cost to the health service of having people ending up in accident and emergency who, if they were getting proper medication, would not be there. It should focus all our minds on what needs to be done.

Asthma is a chronic condition and I believe that people who have asthma should be entitled to participate in the long-term illness scheme, just as those with epilepsy or other long-term chronic conditions are entitled to the scheme. Asthma is a lifelong condition and, as with diabetes or epilepsy, it is a life threatening condition. It should be covered by the long-term illness scheme. More needs to be done to bring down the cost of the medication. I know I am not unusual when I try to stockpile medication while I am away to avoid having to buy my inhalers in Ireland. I bought my inhaler for €38 in Greece last year. In Ireland that inhaler costs me €80, and while I know this is an ongoing issue with the pharmaceutical industry and the Government says it is trying to tackle it, a lot more needs to be done. There is no justification for these exorbitant prices.

With regard to education, the Asthma Society of Ireland has done important work with schools and has provided education packs for schools, which is crucial. Many young people will not realise they have asthma until they have an attack in a PE class or elsewhere. It is important that teachers are equipped and that they know how to react without panic if a person has an attack. The legislation is changing in relation to the use of EpiPens for people with nut allergies. Will the Minister of State confirm whether that is also the case for inhalers? I understand this caused concern in schools due to fears of litigation, but I believe it is important that a person should be able to get an inhaler without a refusal.

I will now turn the issue of GPs and the training for people with asthma to manage their condition. Many GPs are so busy. For example, in my own area of north Dublin we have the lowest rate in the country of GPs per head of population, with one GP for 3,500 people; the national average is one GP for 2,500. If a person goes to visit a GP in north Dublin there is a trail of patients outside. The GPs do not have the time they need to actually work with people to help them manage their conditions. I appreciate that the Minister is doing that with the free GP care for those under six years of age, but this is also important across the general population. The Asthma Society of Ireland has shown that when GPs in Finland engaged in a programme to help people manage their conditions and showed them how to use a peak flow meter properly, there was a 90% reduction in deaths and an 85% reduction in hospital admissions. Education programmes are important, along with managing the costs of medications.

I thank Senator O'Brien for tabling this motion. It is an issue that is important to me as an asthma sufferer. It is quite shocking that Ireland has the fourth highest rate of asthma in the world, and the more we can do to tackle it - by managing people's conditions and also with clean air - the better. One of the best policy decisions made by any Government was the smoking ban, because I know that if anyone smokes anywhere near me I can feel it aggravating my chest. We need to do more to tackle pollution in the city, make the city more attractive for pedestrians and cyclists and promote a more healthy way of life that is good for everybody but especially for those of us who need clean air to survive and to avoid getting into problems.

Colm Burke (Fine Gael)
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I welcome the Minister of State, Deputy Kathleen Lynch, to the House. She attends the House nearly two or three times a week. I thank her for dealing with this very important matter. I also thank the proposer of the motion, Senator Mary Ann O'Brien, and the seconder, Senator Averil Power. Over 470,000 people are affected by asthma, which is a very large percentage of the population. It is essential that we do everything possible to assist those who have asthma. The motion talks about introducing a scheme to assist people with asthma with the financial burden of their condition, to deliver a free annual review for each person with asthma and to conduct an asthma death study nationwide. There is one death per week, which is unnecessary in the sense that 90% of the deaths are preventable. It is important to highlight the decisions that have been taken over the last three to four years. The Asthma Society of Ireland has done much work with all the interest groups - from the Department of Health to the HSE and the various research centres - in trying to progress a more comprehensive policy.

On 1 July 2015 the Government brought in free GP care to those under six years of age, which had not been provided before. Part of that process is the cycle of care for children under six years of age who have asthma. More than 17,000 children have been registered under the programme, which is important for those children. Up to now they did not have that free access to GP care, and where there are young children it is important that they get the best level of care at the earliest possible time. Apart from the effect that asthma has on the individual, when we look at the figures on asthma we see that 1.4 million work days are missed each year, with a total of loss of earnings in the region of €196 million. Parents of children who have asthma are also losing many days from work because obviously they have to stay at home to look after their children and make sure the proper level of care is provided. The estimated cost of those lost days is €67.5 million per annum. This is a huge loss to those people who either have asthma themselves or whose family members have asthma. Everything possible must be done to provide help and assistance for them.

I understand that the national model for care for asthma has been approved by the HSE leadership team and should be rolled out within the next few months. Another recent development is the health care professional education programme, which is a six-part modular theoretical e-learning programme. We need to provide patient education also, and while those issues are progressing, are they progressing fast enough and what can be done to progress it?Access to health care is important. Over 2 million people have a medical card or GP card. It is important that over 2 million people have access to medical care without any real costs. The next question is about the people who do not have that level of care. How can we work with them to make sure they get the maximum benefit from our health services?

This motion is important because of the cost to the health service of people who suffer from asthma. The figures I have seen show that although there are 19,000 visits to accident and emergency departments yearly, only around 5,000 people are admitted to hospital. If we can reduce the numbers who have to attend accident and emergency departments there will be less drain on our health services. One of the frightening figures was that over a hundred people who suffer from asthma were admitted to intensive care. That is nearly two people every week admitted to intensive care. These are extremely frightening figures, which demonstrate why we need to make sure we have the best possible programme. One of the earlier speakers referred to the programmes in Finland and Australia. In Australia, a comprehensive programme was introduced which helped to reduce the level of the difficulties that people with asthma would run into and reduced the number of deaths. Finland has reduced hospital admissions by something like 86%. The evidence is there that if a comprehensive programme is provided and the work is done at local level by working with health care professionals such as GPs and nurses, people can be assisted with a planned programme of care. That is extremely important. We are going down the right road. The question is how to expedite it and make sure that the programme is comprehensive in order to reduce the number of people who have to use hospital services in order to get the care they require.

I thank the Minister of State, the Department and the HSE for the work that has been done over the last three to four years. We have a lot more to do. It is important that we do everything possible to implement the programme in the shortest possible time.

Labhrás Ó Murchú (Fianna Fail)
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I compliment the Senators who tabled this motion. It is clear from the statistics and from our own personal experience of people who have asthma that very often it seems to be below the radar. If we get a common cold, we can feel very sorry for ourselves but we know it will pass very quickly. One has to stop and think why people who suffer from asthma all the time feel they are not being listened to. The Asthma Society of Ireland's report, Living with Asthma, which was published earlier in 2015, is quite clear in stating that people who have asthma feel they are not being listened to. That is why this debate is so important and why we have to bring this issue back onto the radar.

The absolute magnitude of the problem will be found in the statistics. Almost half a million people suffer from asthma and 60% of these do not have it under control. I would not have believed that until we got our documentation and read it. That is why it is important that we are getting the documentation from the Asthma Society of Ireland and also from the Senators who are promoting the motion here this evening. It is more telling, as in any health issue, when one knows someone who has asthma and sees how they suffer. We are told, and I believe it to be true, that asthma does not have to be life-threatening or life-limiting. That is what is important. Yet it is life-threatening and life-limiting. Why has this been allowed to happen? As has already been mentioned here today, if 50 people with asthma go to an emergency department every day, then we have a serious situation. As Senator Power has said, that is one person every 26 minutes. That statistic alone has to be a wake-up call for us. I believe that all intentions on these issues are correct, but there seems to be a piecemeal approach to the whole issue of asthma. We do not have a holistic approach, which is absolutely vital because of the cost of medicines. Asthma runs in families, so it may not be one, two, or three people in a family but a number of people. Unless we have a proper overall strategy, the terrible statistics that have been presented here today will not change in the very near future. We have had a huge debate on the cost of medicines in general over the past number of years and the Government has taken a step in the right direction to ensure that those costs are reduced. That is progress. Why has it not happened in this particular case? I am sure the Minister of State will be able to tell us why it is the case that 25% of people suffering from asthma travel outside the country to buy their medicines because they cannot afford to buy them at home. That statistic alone tells us that the medicines are available in other jurisdictions at a lesser price. The question arises, as it did on our debate on medicines in general, of how it is happening and why it is possible. I do not think we have any reason to disbelieve these statistics.

I have never seen people being over-aggressive in looking for their rights on this issue. Maybe that is part of the problem. Perhaps assertive is a more appropriate word than aggressive. I do not think they are aggressive, but they are suffering. That is important. The economic burden of asthma in Ireland is €500 million every year. We are told this could be reduced by two thirds. I believe that will be the case if we have an overall strategy. In today's debate we are all staying clear of partisanship and politics. It is not about that. It is about all of us trying to make some contribution to the way forward and towards a proper, focused, well thought-out, well monitored and well mentored strategy. That is what people suffering from asthma want. I praise the Asthma Society of Ireland for its fantastic work, not only for its publications or for giving us more information, but for the tenacity of the work it is doing and the way it sticks with it. If the people suffering believe they are not being listened to, we need to listen and respond.

John Gilroy (Labour)
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I welcome the Minister of State to the Chamber. It is a very good and important motion, which I welcome. I thank the proposer and seconder for introducing it here. I find myself in full agreement with all that previous speakers have said. I agree particularly with Senator Ó Murchú, who said that we all think we know plenty about asthma until we actually do a bit of research into the figures and facts behind the obvious presentation of it. I am psychiatric nurse. I worked for nearly 30 years in hospitals and have come across asthma in its acute and subacute forms.It was only when we started to read the research papers we were given on this issue that we realised the impact the condition has at the personal and societal levels. I cannot conceive of anything more terrifying or alarming than finding oneself unable to breathe.

Some of the statistics provided today give rise to serious concerns. Senator Mary Ann O'Brien pointed out that Ireland has the fourth highest rate of asthma in the world, while Senator Power noted that one in five children aged between 13 and 15 years have asthma. I was unaware of these figures, which are incredibly high. Another awful statistic is that one person dies from asthma every week. The general public is not aware of these facts, which should be disseminated more widely.

The medical approach is best left to medical experts in consultation with sufferers and user groups. However, politicians have a role in the roll-out of policy at the medical, personal and societal levels. It is great news that a national model was approved recently. Will the Minister of State indicate what is the timeframe for the roll-out of the new programme?

Policy makers must consider ways in which we can make life easier for people who suffer from asthma and how the societal response to the condition can be made more cost-effective. Ultimately, everything comes down to money. Senator Burke spoke, for example, about the number of days at work and in school lost as a result of asthma. The figures he cited are alarming. I note also that 4,700 people are admitted to hospital as a result of asthma on average each year, with each hospital stay averaging 3.1 days. This means the treatment of asthma accounts for 15,000 bed days in hospital every year.

Approximately 60% of asthma sufferers do not have their condition under control and 40% of this group cite the cost of their medication as the main reasons for this lack of control. Asthma has a personal and societal cost. A recent survey carried out by the Asthma Society of Ireland found that asthma sufferers spend between €100 and €144 per month on asthma medication. Under the drugs payment scheme, no family or individual is required to pay more than €144 per month for medication. However, a person who pays €144 per month on medication will need to earn €3,500 before tax just to buy his or her medicines for the year. To put this figure in context, a person suffering from asthma who earns the average industrial wage needs to spend 10% of his or her earned income on medication. People suffering from asthma also report that they pay €250 on average per annum for general practitioner services and lose an average of 12 work days per annum. These are substantial costs for the individuals concerned.

In addition to the large number of hospital admissions caused by asthma, Senators Ó Murchú and Power pointed out that the condition is also responsible for approximately 50 attendances per day at accident and emergency units. I wonder if the budgets for community care and acute hospital services are structured in such a way as to make it impossible to take such matters into consideration. If the budget for the former declines, surely savings will be achieved in the latter budget. They seem to be structured in such a way that these issues cannot be taken into consideration.

What would be the net cost to the Exchequer of adding asthma to the 16 conditions covered by the long-term illness scheme? The figure should take into account the savings that would be achieved in many other areas and the significant number of asthma sufferers who are already covered under the medical card scheme. There will be net and gross figures for the cost of including asthma in the long-term illness scheme. I am interested in finding out the former. It would be fantastic if the Minister of State intended to include asthma in the scheme. If not, does she intend to roll out any other scheme that would specifically target asthma? I look forward to hearing her response.

David Cullinane (Sinn Fein)
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I thank the Minister of State for coming to the House to take part in this debate and commend the authors of the motion on raising the issue of asthma in the Seanad. I was diagnosed with asthma a number of years ago, almost by accident. I thought I had a bad cough linked to hay fever, a condition from which I suffer badly in the summer. Most people do not realise that there is a connection between hay fever and asthma and it took me some time to figure out the link. I was prescribed antibiotics for what I believed was a cough but it subsequently transpired that I was suffering from asthma. The condition is often seasonal as I suffer most in the summer months when I also suffer from hay fever.

A staggering 470,000 people in the State are living with asthma. Even more disturbing is the statistic that one person dies from the disease every week. Some of the facts and figures presented to us are incredible. They demonstrate that asthma is a major problem on which a substantial amount of money is spent in the health service every year. It is all the more important, therefore, that the issue is discussed in the House today.

Attention must be drawn to the dangers of asthma and every effort made to put pressure on the Government, including the Minister of State, Deputy Kathleen Lynch, to take appropriate action to assist the almost 500,000 people in the State who suffer from the condition. With regard to the management of asthma, the first step of the Health Service Executive's national clinical programme for asthma should be funded. The Asthma Society of Ireland estimates that this would cost approximately €2.5 million. We often hear about the recovering economy, more fiscal space and more money about the place. Given that all Departments are facing increased demands for more expenditure, I understand the need to prioritise. However, €2.5 million, while not an insignificant sum, is not an especially large amount when set against overall State income from taxation. The Government can afford to provide the funding required to implement the first step in the national clinical programme for asthma. The issue is whether it has the political will to do so. According to the Asthma Society of Ireland, 59% of people surveyed believe asthma care would improve in Ireland if the programme were implemented. It is disappointing to note that this it remains largely unimplemented, despite being adopted in 2011. As a result of this failure, the Asthma Society of Ireland has called on the Government to set out a revised timetable and framework for its full implementation. This is a reasonable request on the part of the society.

The second step required is to introduce a free annual asthma review and written asthma action plan for all asthma sufferers. This is a common sense and reasonable proposal, although clearly the issue of costs must be considered. It is especially important given that it is reported that 59% of asthma sufferers have not had their condition reviewed in the previous years. It is also alarming to learn that 72% of respondents in a survey did not have a written asthma action plan.

A free annual asthma review is vital for good asthma management and care. Chronic disease is responsible for the bulk of the workload of hospitals and its incidence is predicted to rise. The long-term care of patients with conditions such as asthma represents a significant unnecessary cost burden on the acute hospital services where more timely and appropriate care could be provided in the primary care setting. According to the Asthma Society of Ireland's Case for Change document, asthma is estimated to cost €500 million per annum. While some measures for the management of asthma and diabetes were announced in the most recent deals with general practitioners, these are limited in scope as they allow for just two years of asthma and diabetes care and only to those already receiving a certain level of care.

A more fundamental debate about health service provision is required. On the Order of Business this morning, Senators raised the national debate on whether universal health insurance will be introduced and what type of health model or service will be in place in future.We need to reorient our health services and have a system based on need. Its central focus should be placed on prevention, health promotion and primary care. This is something on which the Government has done some good work, as should be acknowledged, as we have seen more focus on primary care centres. We now see much more value in greater investment, prevention and primary care. We must build on that in the time ahead as well.

The model of universal health care that my party is working to achieve includes GP and other primary care, as well as allied health professionals, medicines, dentistry, hospital and long-term care. It deals with many of the issues quite rightly raised by Senator Gilroy regarding cost of health care for many citizens. We end up paying anyway, whether it is through tax or private health insurance, or else people do not get the health care they need. It is a big debate for all politicians to have as to whether we want a health service that delivers the health needs of people, going beyond reactive health care to invest properly in primary health care and prevention. It costs money but we must have that debate. Are we prepared as a society to pay for proper health services? That forms part of this response as well, as it requires funding. It is easy for us in the Opposition to say the Government should do certain things, but we must be able to say we are prepared to pay for it or ask people to pay more tax for that health care. We cannot talk about universal health care or universal health insurance if we are not prepared to pay for it.

Quality of care is essential and must be at the core of the service. Outside of waiting lists for specialists, perhaps nowhere is access to health services more unequal than in primary care. In primary care, entitlements are given or denied on the basis of household finances or employment status rather than medical need. I commend the authors of the motion. It does not just mention the problem as it also puts forward solutions. It calls on the Government to do a number of things, some of which I referenced. The Government should consider the recommendations being made by the authors of the motion, as they have done their research, as well as the advocate organisations. We all want the recommendations to be implemented.

Denis O'Donovan (Fianna Fail)
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I will call Senator Mullins next, if that is okay with Senator Eamonn Coghlan, because Senator Mullins will be taking the Chair. I welcome to the Gallery Mike and Winnie Barbour, who are visitors to the country. Winnie is an aunt of our good colleague, Senator Comiskey. They are welcome and I hope they enjoy their visit.

Michael Mullins (Fine Gael)
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I welcome the Minister of State, Deputy Kathleen Lynch, to the House and thank her for coming her to facilitate this debate. I particularly pay tribute to Senators Mary Ann O'Brien and Averil Power for giving us the opportunity to discuss the issue, highlighting the numbers of people who suffer from this condition. I welcome the representatives of the Asthma Society of Ireland and compliment them on the information that has been supplied. I am pleased to inform them that I helped with their recent church gate collection in my home town of Ballinasloe and we got a fantastic response.

I did not realise the very significant numbers of people who suffer from asthma and we all know somebody who is affected. I certainly did not realise it reached approximately 500,000 people, with a very significant cost borne by the health service. It is estimated that 50,000 people use the GP out-of-hours services for the treatment of acute asthma every year, with 19,000 people visiting accident and emergency departments because of acute asthma. There are 5,000 people admitted to intensive care because of the condition. It is worrying that one person per week dies as a result of an asthma attack, but the good news is that 90% of those are preventable if services are provided and resources are made available. It is very encouraging that people with asthma can lead a very full life, hold full-time occupations and participate in sport at the very highest level. These are the positives. The Government in recent times has provided GP care for those under six, which eases the burden on families. That will be extended to those under 12, and those over 70 already have free GP care.

A previous speaker referred to a negative in the form of medication costs. Nobody has explained to me logically why the cost of medicine is so high in this country. I was out of the country for a few days in the summer and I met a number of people on the flight whose main purpose for taking a break in the sun was to purchase medication for various conditions at a fraction of the cost here. They paid only approximately a third of the cost that we would pay in Ireland for the same medication. I cannot rationalise the issue so perhaps the Minister of State will refer to the matter in her response.

Much has been achieved in recent years in heightening awareness of and assisting people with asthma. We need to set some priorities for 2016. The model of care for asthma is due to be launched in the next few months, and the resourcing of that model of care must be a priority for the Government and its successor in a few months. We must create awareness and implement the national clinical guidelines for the management of acute asthma attacks in adults. Integrated care services for patients with asthma must become a priority for the Government. Senator Power referred to educational programmes for young people in schools in order that asthma in young people can be detected early. Young people must be made aware of how to minimise the impact of asthma and how to seek assistance and medical care at an early stage. We want to ensure that nobody in future will lose his or her life as a result of an asthma attack and we want to minimise the impact of asthma on the health services. We want to see a reduction in the number of days lost at work and earnings forgone by parents as a result of having to take children with asthma to hospital in emergency cases. The loss of production to the country is also significant. We can work together as politicians to ensure resources are provided, with help and assistance made available. The limited resources available to the State should be used in the most effective manner.

I compliment Senators Mary Ann O'Brien and Averil Power on bringing forward the motion. I look forward to hearing the Minister of State's response.I hope she will have positive news to impart to the House and to everybody adversely affected by asthma in this country.

Eamonn Coghlan (Independent)
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I welcome the Minister of State to the House. I would also like to thank and congratulate Senator Mary Ann O'Brien and Senator Power for bringing the motion to the House. I had not intended to be here or even to speak on the motion today. I had a meeting upstairs in my office and changed my mind about attending when I heard Senator Mary Ann O'Brien speak in an up-front fashion. I was astounded to learn from her that in Ireland there are 470,000 people who live with asthma, that Ireland has the fourth highest prevalence of asthma in the world, that one in ten adults and one in five children suffer with asthma and that more than one person dies every week in Ireland from asthma although 90% of asthma deaths are preventable. Therefore, it is important to highlight the effects of asthma on society.

When I was growing up as a young boy, and as a young sports person, one never heard much about asthma or its affects. One only heard about it when it was given as the reason a young person did not play sports, but such occurrences were rare and few. Society has changed considerably over the past 40 or 50 years and so too has the affect of asthma on society, not just in Ireland but around the world. I have often wondered why more people than ever before suffer from asthma. The ban on burning coal and smoking cigarettes in public places has helped Irish society but asthma still affects us in a big way. Why?

We know that asthma can be beaten and controlled. As a matter of fact, from my sports career I am familiar with the female world record holder for the marathon, the great Paula Radcliffe. She could run a marathon in two hours and 15 minutes, yet she suffers from asthma. The great Haile Gebrselassie, a multiple world record holder, Olympic champion and world champion, has also competed over the years despite having asthma. Listened to the debate on the monitor in my office, I heard Senator Power say that the great David Beckham suffers from asthma. I know from my involvement in sports and coaching young children that quite a number of them have exercised-induced asthma. Why?

As a parent I have also witnessed asthma at first hand. My son, John, had asthma but he happens to be a national athletics champion and even won a gold medal for Ireland in the European Cross Country Championships a number of years ago. Senator Ó Murchú has speculated that perhaps asthma runs in families. My son has inherited his talent for running but there is no history of asthma among our immediate family and extended family. My son is the only one in my family to suffer from it. My wife and I have tried to find out why this is. We were fortunate enough to have support in that we were able to find the best medical team available that prescribed the proper medication. We were able to identify the correct time of day that he should use a flow meter, and whether it had to be done before or after exercise. We also recorded everything daily for a long period in order to understand the condition. Unfortunately, there are plenty of families who do not have the same support mechanisms available to them when it comes to tending to their asthmatic conditions.

People often wonder whether asthma comes from food, the musty damp conditions that are prevalent in some homes today, animal hair, pollen, carpet fibres and so forth. My wife and I investigated whether these were the cause. We even went to the extent of moving our son's bedroom. Originally his bedroom was in the most northerly position of the house, where it did not get as much sun, and it tended to be a little damp. We hoped that by moving him to another bedroom his condition would improve, and it did change his condition. Over the past four or five years his asthmatic condition seems to have disappeared and he never talks about it anymore.

Asthma is a serious problem and, as Senator Ó Murchú has said, we need to focus going forward. Senator Mary Ann O'Brien has recommended that we implement the HSE's national clinical programme for asthma, introduce a scheme to assist people with asthma with the financial burden of their disease, and deliver a free annual asthma review for each person with asthma, as recommended in the HSE national clinical programme for asthma. I support the motion and look forward to hearing the remarks of the Minister of State.

Denis O'Donovan (Fianna Fail)
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I had not planned to speak today but it is important that I put on record my appreciation for the motion moved by Senator Mary Ann O'Brien. Sometimes we get so bogged down in our own little circles. I was in the Chair for some time and I was not sure what the motion was about. The motion is worthwhile and I thank her for tabling it.

Thankfully, I have never smoked in my life and I have not had asthma. A son of mine who is now an adult has suffered from asthma since he was a small child, yet he has had a successful rowing career and still runs a few marathons. There was a psychological aspect to his asthma because he always had to have his little inhaler in his togs when he rowed, whether it was in the Lee Valley in Cork, Bantry Bay or the international Atlantic Challenge competition. As a parent, one is always conscious of the fact that an asthma attack can strike at any time. As my son grew older he was able to deal with it himself. Thankfully, he seems to have grown out of asthma, particularly once he passed the age of 24 or 25. He is still conscious of it, but asthma sufferers can live a normal life.

The motion calls for more to be done to ensure that people do not die from asthma and that they do not have to run in and out of the accident and emergency department taking up precious hospital time. Asthma is a treatable condition. I listened to Senator Eamonn Coghlan and I am not sure whether asthma is a climate issue. Some people with the condition have found it to be upset by having animals in their homes. Carpets can be another trigger. I took carpets out of the rooms in my family home and replaced them with timber floors. Some of these measures can help the condition. I have a first cousin, who has been resident in America for many years, who suffered intensely from asthma as a child. I remember what happened sometimes on the way home from mass at the nearest church in Kilcrohane, which was over a mountain. I am one of 11 children and myself and my sister used to give my cousin a piggyback when he suffered an asthmatic attack in order to get him home. Once he moved to the United States permanently his asthma disappeared. I met him recently for the first time in 16 years at a funeral and he said that it never bothered him again, so perhaps asthma is affected by climate. We should be cognisant in Ireland that we have a climate that is conducive to asthma, chest conditions and various other ailments. However, there is no magic button to solve the issue.

We have had a worthwhile debate and I thank the Minister of State for coming to the Seanad to debate the issue. In conclusion, I offer my support and thank Senators Mary Ann O'Brien and Power for sharing their experiences, and the same goes for the Asthma Society of Ireland. An asthma attack is very frightening for young children. I have witnessed it and I know, as a parent, that one worries and seeks ways to cope with the condition. Today's motion is very important and I am sure the Minister of State will respond sympathetically. I also thank her for allowing me the grace to attend to another commitment outside this House tonight. I am grateful to have been allowed to say a few words of support on a simple but important issue that the health sector and society has to deal with.

Terry Brennan (Fine Gael)
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Ar dtús ba mhaith liom fáilte a chur roimh an Aire. I, too, want to be associated with the compliments expressed to Senators Mary Ann O'Brien and Power on their motion and congratulate them. The motion is simple but it is on a condition that affects many people.

As I am the last speaker, many of my figures have already been quoted. It has been estimated that nearly 450,000 people in Ireland have doctor-diagnosed asthma, with many other cases going undiagnosed.It is one of the most common chronic conditions among Irish children and young adults. Despite more than two decades of international asthma management guidelines, the majority of people with asthma in Ireland continue to suffer avoidable illness and poor quality of life. Approximately 50,000 patients are established to use the GP out-of-hours service for the treatment of acute asthma in a year, as stated by my colleague, Senator Colm Burke. More than 19,000 people visit accident and emergency departments annually with acute asthma while more than 5,000 patients are admitted to hospital. Of these, approximately 100 are so severely ill that they are admitted to intensive care units.

The HSE's national clinical programme for asthma was set up to design and standardise the delivery of high-quality asthma care to all who need it. Through the understanding of the current health status and needs of people with asthma, the programme can target measures where they are needed and measure the effectiveness of any interventions. The initial focus of the national clinical programme for asthma has been the development of asthma education initiatives for patients and health care professionals, the development and implementation of national asthma guidelines and the organisation and better integration of national asthma services at primary and secondary care level. This approach has been shown to be effective at international level with significant improved outcomes both for patients and care givers. The national clinical programme for asthma is also focusing on improving asthma control in the community, thereby reducing acute asthma attendances at emergency departments, in-patient admissions and deaths from asthma. When one considers that there is one death per week according to my note, albeit I understand it may even be one per day, a large number of people are dying from asthma attacks. The national clinical programme for asthma has also focused on the development of national asthma guidelines based on international best practice both for acute care and ongoing asthma management. Emergency adult asthma guidelines and emergency paediatric asthma guidelines have been published and the reports can be located on the HSE's website.

Asthma control in general practice guidelines for managing patients with asthma in primary care settings have been developed and approved by the Irish College of General Practitioners. The model of care for asthma has been approved by the HSE leadership team and is due to be launched in the coming weeks. A national clinical programme for asthma will also contribute to the development of a chronic disease pathway and is being progressed by the HSE. A self-learning, six module, e-learning theoretical programme on asthma, based on the national evidence-based guidelines and developed by the NCPA in conjunction with the Asthma Society of Ireland, is freely available. In addition, a practical workshop is also being delivered by the respiratory clinic and nurse specialists for staff in primary and secondary care settings. To reflect the introduction of the under-sixes' free GP care contract, the NCPA is also in the process of updating educational programmes.

I will finish there, the rest of what I had to say having already being mentioned. I congratulate my colleagues for bringing forward the motion.

Michael Mullins (Fine Gael)
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Senator Moloney is next and has six minutes.

Marie Moloney (Labour)
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I do not need six minutes as I am not an expert in this field. I had no intention of speaking on the motion and have come to the House to relieve our party spokesperson on health. I was listening to the debate in my office and the only reason I am going to speak is because I am now asthmatic. I was diagnosed when I was pregnant many moons ago. I would not even consider myself an asthmatic because I could go for two or three years without ever having to use an inhaler. It is just something that crops up every now and again.

This summer, however, when I was working here I began to get worse and worse. It got to a point where I could not even climb the stairs outside without stopping at the top to cough and get my breath back. I was doing all the usual things we all do involving nasal sprays, nasal washes and using the normal inhaler that I always keep in my bag just in case, but none of it was working. I went to the doctor saying "Flip this for a game of soldiers, there must be something more wrong". I was prescribed a new inhaler which cost €85. I am not complaining about the cost which I can afford, but there are many people out there who cannot afford it. It is quite expensive for people when they are put on something as strong as that. People have been lobbying, including the Asthma Society of Ireland and ordinary people who suffer from asthma, to have asthma placed on the long-term illness scheme. I can understand the problems that would arise if that was to be done because there is a question as to where one would draw the line. Does one go from the child with croup up to those people with full-blown asthma which threatens their lives? In any event, I emphasise the cost of the medication, which is very costly for people.

I have been in a country where one can walk into a shop and buy these medicines over the counter without the need for a prescription. I cannot understand why one has to have a prescription in one country but not in another, notwithstanding that it is the same medication which will have the same effect. I remember when I was diagnosed first, I was taking the medication in liquid form. One got it over the counter and took it with a spoon. I remember the doctor saying to me that it really needed to go on prescription because it was so dangerous. People do not realise how dangerous it is because it opens the airways. One can take too much and collapse on the street. I had never realised how dangerous it was. I went onto the inhaler and I do not think it is even possible to get it in liquid form anymore. I am not sure because I do not use it.

I thank the Senators for raising the issue. While to some it might seem like a very mild illness compared to other illnesses out there, for the person who suffers badly with asthma and cannot breathe, it is dangerous. A friend of mine was walking along the street one day and could not find her inhaler. When she got to her car she had to hold on to it because she started to collapse. She fell on the street. Luckily, someone came along who had an inhaler and gave it to her. I think that girl would be dead today had that stranger not come along with an inhaler in her bag. We hear all the time of people dying from asthma and it is very sad. I acknowledge that the Minister has a whole clinical programme going on. There is a long briefing before us and Senators have put forward a very detailed motion for which I thank them. I welcome the debate and await the Minister of State's reply with interest.

Kathleen Lynch (Cork North Central, Labour)
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I thank Senators Mary Ann O'Brien and Power and the Asthma Society of Ireland for their engagement over a long period in terms of the most Government appropriate response to asthma. I thank the Members who contributed to the debate. I say on most if not all occasions I stand up in the House that the Seanad gives people an opportunity to discuss issues that do not get the type of air time they may deserve.It is a very good platform in that regard. The most peculiar matters are discussed in here. In this instance, we are discussing something that could well affect each and every one of us. I thank the Senators who tabled this motion and the Cathaoirleach for the opportunity to discuss it.

I do not think there is any dispute between on us on this matter. I am delighted to support the motion before the House, which acknowledges the Government's commitment to the provision of primary care to people with chronic diseases such as asthma, which remains a significant challenge for our health services. The motion also recognises that we are promoting healthier lives for everyone in our communities. I agree with the point that has been made with regard to medication. I have read through the speech that has been prepared for me but I am not sure whether it includes a reference to this issue, which I discussed with the president of the Irish Pharmaceutical Healthcare Association recently. I understand that the Department will enter into further discussions with the association within weeks. I will ensure the cost of asthma medication is on the agenda for those discussions. I am happy to make that promise here.

I acknowledge those involved in the Asthma Society of Ireland and the HSE's national clinical programme for asthma. I pay tribute to them for their joint efforts in improving the lives of asthma patients. I am aware of the statistics highlighted in a report produced by the society, The Case for Change: Implementing the National Clinical Programme for Asthma, which was published in 2014. These statistics, which can also be found in other available data, make it clear that asthma is a serious burden for patients and our health services. This is compounded when one considers that up to 90% of deaths from asthma are preventable. I do not intend to get into a debate on statistics. One can get different statistics depending on what week it is and on what source one uses. We have statistics from the CSO. At times, we cannot be certain about the exact cause of death or the exact numbers. This point is sometimes made in debates about suicide. In 2012, the CSO recorded 39 deaths from asthma, 22 of which involved people aged 85 or older. There was an increase in 2013, when 54 deaths were recorded, 35 of which involved people aged 85 or older. This was followed by a decrease last year, when 37 deaths were recorded, 15 of which involved people aged 85 or older. This is still too many. I agree that we must strive to address this as soon as possible.

The HSE's national clinical programme for asthma was set up in 2011 to design and standardise the delivery of high-quality asthma care to everyone who needs it. The programme has made significant progress since its establishment. Initially, it focused on the development of asthma education initiatives for patients and health care professionals, the development, implementation and organisation of national asthma guidelines and better integration of national asthma services at primary and secondary care levels. This approach has been shown to be effective at international level with significant improved outcomes for patients and care givers. The national clinical programme for asthma is focusing on improving asthma control in the community. Its aim is to reduce acute asthma attendances at emergency departments, inpatient admissions and deaths from asthma. Among the specific priority solution areas being explored by the programme are the development of a national model of care with guidelines, care pathways and treatment protocols for use in primary and secondary care settings. This work is being carried out in conjunction with other national clinical programmes, including those in the areas of emergency medicine, acute medicine, critical care, obstetrics and gynaecology, paediatrics and neonatology and primary care.

The development and delivery of asthma education programmes for health care professionals to underpin the guidelines is an important aspect of the work of the national clinical programme for asthma. Integrated care initiatives that aim to improve the diagnosis and management of asthma patients in the primary care setting, with links to specialist adult asthma services, are also being developed. Those involved in the Asthma Society of Ireland are probably more aware than most that the doctor is not always needed in these cases. We can do far more if our approach involves getting specialist nurses or health care professionals involved in the management and education aspects of this matter. I know that is the society's approach as well. The national clinical programme for asthma has developed national asthma guidelines based on international best practice for acute care and ongoing asthma management, including emergency adult asthma guidelines and emergency paediatric asthma guidelines. These reports can be found on the HSE website. The emergency adult asthma guideline, which is a national clinical guideline for the management of acute asthma attacks in adults, has been prioritised and quality assured by the Department of Health's national clinical effectiveness committee. It is due to be published and launched next week.

Work is ongoing on the emergency paediatric asthma guidelines, known as the national clinical guidelines for management of acute asthma attacks in children. It is intended that these guidelines will be submitted to the committee in 2016. Guidelines for managing patients with asthma in primary care have been developed and approved by the Irish College of General Practitioners. They were launched in May 2013 and are available on the college's website. The national clinical programme for asthma is planning to work with the college to update these guidelines. The model of care for asthma has been prepared and is due to be launched in the coming months. The model details how physicians, nurses and other health care professionals will work with engaged patients to make the clinical decisions that are most appropriate to their circumstances. It also sets out how they can collaborate with specialist colleagues in providing a safe and seamless patient experience within our health system.

It is appropriate to say at this stage that an obvious need exists in this regard. The economic and health impacts of asthma on society and on patients are also obvious. That is why one of the first two chronic disease management programmes to be developed in the primary care sector relates to asthma. That, in itself, is an indication of the realisation that this is an issue about which we can and should do something. In anticipation of the launch of the model of care for asthma, the national clinical programme for asthma has been developing and preparing for the roll-out of the asthma integrated care demonstrator project across two initial sites. These are linked to the catchment areas of the Midland Regional Hospital in Mullingar and Connolly Hospital in Dublin. The demonstrator project plans to improve the diagnosis and management of asthma patients in the primary care setting with links to specialist adult asthma services. Its aim is to improve health outcomes and reduce service demand. Two new clinical nurse specialist posts have been approved for this project. They were advertised last week. It is hoped that the recruitment process will be completed before the end of the year. The HSE will consider expansion of this initiative based on the success of the demonstrator project.

The Asthma Society of Ireland's report, The Case for Change: Implementing the National Clinical Programme for Asthma, highlights the importance of asthma education for health care professionals and patients. The national clinical programme for asthma agrees with this approach. A modular self-learning programme, which is based on the national evidence-based guidelines and was developed by the national clinical programme in conjunction with the Asthma Society of Ireland, is available online for health care professionals who wish to update their knowledge. This programme will enable health care professionals to underpin their skill sets with theory. A similar programme for general practitioners is available on the website of the Irish College of General Practitioners. A practical workshop is being delivered by the respiratory clinical nurse specialists for staff in primary and secondary care. The national clinical programme for asthma is updating education programme materials to reflect the introduction of the free GP care contract for those under the age of six. Just as it is important to provide appropriate asthma education to health professionals, it is equally important that relevant education is made available to asthma patients. In this regard, up-to-date information is available for patients and their families and carers. The national clinical programme for asthma has implemented easily accessible patient asthma education supports in conjunction with the Asthma Society of Ireland to assist guided self-management for this chronic condition. These supports are available on the websites of the HSE and the Asthma Society of Ireland.

As I said earlier, deaths related to asthma are preventable. In this regard, the national clinical programme for asthma has initiated research work which will involve examining acute asthma deaths in Ireland. The aim of the project is to identify and understand preventable factors relating to the management and self-management of asthma so that we can improve the further care of people with asthma and prevent further asthma deaths.The objectives are to identify all asthma deaths in Ireland during the study period; explore the circumstances surrounding each death from asthma, including trigger factors, awareness at school or work, environmental conditions, lifestyles and activities, medication and adherence to treatment plans, and organisational aspects of care; analyse key themes, particularly preventable factors; and propose solutions for adoption by the national asthma programme in respect of clinical practice, service provision, education of professionals and patient education. This work will be led by the programme's clinical lead and its public health specialist. I have asked the HSE to start this work as soon as possible and I look forward to its findings, which I hope will lead to fewer asthma deaths in the future.

It is evident that the asthma programme and the Asthma Society of Ireland have been working strenuously together to address key issues relating to asthma care. Progress may be slower at times than everyone would like but it is encouraging that steady progress has been made, especially at a time of scarce resources. As our financial circumstances improve, I am confident that further improvements for asthma patients will be achieved.

I am pleased that the Government is playing its part in improving asthma care. It is reforming the system of health service eligibility and seeking to make it fairer. For many years, Irish patients have had universal eligibility for acute hospital services but the first point of contact with the health service, provided by GPs, has only been provided on a public basis to those on low incomes. The provision of universal GP access through greater public investment in primary care services is a critical reform in resolving inequities and rebalancing services towards earlier prevention. We want to shift the emphasis in our health system from an "illness model", dependent on care in hospitals, to a model where primary care services are strengthened and health and well-being are promoted. A number of building blocks are fundamental to this shift from reliance on acute care to where it is best accommodated at primary care level. GP care without fees is one of the principal building blocks to make this happen. The Government is committed to introducing, on a phased basis, a universal GP service without fees. Many people delay or even avoid going to their GP for essential medical care as they simply cannot afford the €50 or €60 fee per visit. When people delay going to their GP and getting regular preventative and screening care, it results in the late detection of illness, poorer health outcomes and greater pressures on our hospitals - pressures that our hospital system can ill-afford. The Government wants this to change and good progress has been made.

The new contract with GPs for children aged under six includes for the first time in primary care the provision of a cycle of care for child patients with asthma. The asthma programme and the Asthma Society of Ireland have welcomed the introduction of this first step in the provision of a comprehensive programme for asthma across primary and secondary care. The cycle of care includes key actions such as checking inhaler technique, provision of a written asthma action plan, review of asthma medications and recording of smoking status of the home. In addition to the introduction of GP care without fees at the point of access for children aged under six, GP care without fees to all persons aged 70 years and over was introduced. These represent the first phase in the delivery of a universal GP service. On reading the research into asthma, I was not as conscious that the majority of deaths occurred in the over 85s age cohort and, therefore, free over 70s GP care provision will be crucial. The under-six arrangements will also be important in the context of education and developing practice but the over 70s provision will be equally important.

Under the new arrangements, effective from 1 July 2015, an additional 270,000 children aged under six will benefit from GP care free at the point of access. The new extended GP service applies to all children in this age cohort, including the 166,000 who held a medical card or GP visit card. To date, more than 210,000 children have been signed up for the under six service, which includes age-based preventative checks focused on health and well-being along with the asthma cycle of care mentioned earlier. More than 17,500 children have been registered for the asthma cycle of care by their GPs, under which each one of them will be reviewed annually by their doctor. The introduction of GP care without fees at the point of access to all persons aged 70 years and over commenced on 5 August 2015. To date, in excess of 47,000 people have registered for this service.

The HSE, the Department of Health and the IMO have commenced talks on a new GP contract, and a priority of these discussions will be the inclusion of chronic disease management for patients. As a first step in this process, agreement has been reached on the introduction of a diabetes cycle of care for patients with type 2 diabetes who hold a medical card or GP visit card. The cycle of care aims to augment the service available to GMS diabetic patients prior to the introduction of a comprehensive structured chronic disease programme. The diabetes cycle of care commenced on 1 October and to date, more than 55,000 patients have been registered for the service by their GPs. Currently, in excess of 2.1 million people can avail of free GP services, more than 1.7 million of whom can also avail of free prescribed approved medicines, subject to the relevant prescription charges. The Government remains committed to expanding free GP to more patients and in this context budget 2016 committed to a further extension of GP care without charges to children aged 11 and younger.

This will be subject to negotiation with the IMO in respect of the scope of the service to be provided and the fee arrangements to apply and will be implemented in the context of overall new arrangements and not as a stand-alone extension or amendment to the current contract. If we were going to bring it up to the under 12s, we should have brought it down to the over 65s as well, but I did not get my way on that. I am confident that the ongoing work of the HSE's asthma programme and the Government's commitment to introduce universal GP care for the entire population will over time reduce the cost burden on asthma patients. Meanwhile, where asthma patients do not qualify for free medicines under the GMS or the drug payment scheme, they or their family have to pay a maximum of €144 each month for approved prescribed drugs, medicines and certain appliances for use by them or their family in that month. I hope the negotiations with the IPHA will reduce that burden on patients.

I am confident all these initiatives will have a positive impact on the health of our nation, including asthma patients, and will reduce the burden on those patients and on our hospital services. I thank the Senator again for raising this issue. It is an excellent subject for debate and it will raise awareness of this issue, which is crucially important. Somehow or other, we seem to look on asthma and other chronic conditions as ailments that people have to get on with when, in fact, there are mechanism for ensuring people can live a much healthier, longer and more productive life if they are managed properly.

Mary Ann O'Brien (Independent)
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I thank the Minister of State for her response and all the Senators who took time to contribute. I would like to acknowledge the work of the Asthma Society of Ireland. As we have all admitted, we have friends with asthma and I was aware of this at the start of my journey on this issue but I did not know that almost 500,000 citizens are affected by the disease. Every Member should have been present for the debate, which has been positive. I loved the word "promise". The Department will have discussions with the IPHA regarding the cost of medication. It is the equivalent of a small mortgage. The Minister of State said individuals or families who do not have a medical card, which amounts to a significant number, will only have to pay a maximum of €144 monthly but-----

Kathleen Lynch (Cork North Central, Labour)
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I did not say "only"; I took that out of my speech. It is in the Senator's copy but I did not say the word.

Mary Ann O'Brien (Independent)
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The Minister of State and I agree it is a small mortgage.

Kathleen Lynch (Cork North Central, Labour)
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Yes.

Mary Ann O'Brien (Independent)
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As Senator Power said, she can afford that but many cannot. I have read the Finnish study and the Minister of State outlined the way she is going. Education is a key factor and she is on that journey. It is staggering what Finland achieved. Aside from the 500,000 people who are suffering, there is a significant cost to the health service, which could be dramatically reduced.Senator Gilroy said that asthma accounts for 15,000 bed days a year in hospital. If we reduce that by 90%, it will be down to 1,500 bed days every year. Those bed days could be used in other ways.

I will return to the issue of education. The Asthma Society and the HSE have given us much information. That is what we are discussing and we can educate parents, families, patients, GPs, nurses and pharmacists. Senator Power mentioned the EpiPen and that an inhaler can now be dispensed by a pharmacy without prescription. My little daughter is only a mild asthmatic. I was in Kilkenny at the heritage conference recently when she had an attack and she called me. She did not have her inhaler because she has mild asthma. I said, "What do you mean you do not have your inhaler?" I went to the presentation in Kilkenny and ran into the pharmacy. The pharmacist said she could not give it to me because I did not have a prescription. The Minister of State has passed the legislation. She should inform pharmacists soon that they can dispense inhalers without a prescription because it is serious when a child or adult cannot breathe. The training will be rolled out but pharmacists should know that they can give inhalers to help people.

We talked a lot about Ireland. Unfortunately, we have the fourth largest instance of asthma in the world. It is not something we are proud of and we all question why this is. I will ask the Minister of State a question about joining the dots. Environmental conditions contribute to asthma and allergies and air quality has a huge effect on asthma sufferers. Will the Department of Health and Children join the Department of Environment, Community and Local Government and the Environmental Protection Agency, EPA, to monitor the air quality in Ireland and crystallise a vision and strategy for the future to improve our air quality? It is fantastic that we have stopped smoking and we have great plans on climate change. We get our pollen counts from the UK because we do not have our own pollen count. Pollen is the name of the game for asthma sufferers in the summer months. Damp, mould and stress are also factors. Thoraxhas published peer-reviewed research. The Thoracic Society of Australia and New Zealand cites processed foods, a diet high in sugar and fat, and fast food. Senator Eamonn Coghlan said earlier that long ago we knew a few people with asthma but it has become an epidemic. The HSE should keep up to date with the peer-reviewed research. Diet is becoming a modern plague and sometimes what we eat is a worry.

I thank Senator Mullins who was collecting for the Asthma Society earlier. If any Senators want to offer their time at the weekend to collect for the Asthma Society, it will be delighted. Senator Gilroy said correctly that we have a plan and now we need the timetable. I thank the Minister of State for the timetable she has laid out. In addition to her promise on medications, I ask her to push the HSE to move on in a timely manner. The Asthma Society is doing great work but we have a serious problem in this country.

We have discussed our damp, mouldy climate and diet. We have to move in a timely manner. Much of the research and work has been done since 2011. Given her responsibilities in the mental health area, the Minister of State has many things to worry about. This is a bit of low-hanging fruit. It is chronic but we have to address it.

The Acting Chairman will make me sit down. I could talk for the evening because I have so much to say. We should communicate with the pharmacists so they know they can give out inhalers without prescription. I thank everyone and ask them to continue to discuss this subject because almost half a million of our citizens are suffering from this. The Minister of State should reduce the cost of the medication and perhaps the introduction of a chronic illness card should be on the agenda in future for asthma sufferers.

Michael Mullins (Fine Gael)
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When is it proposed to sit again?

Colm Burke (Fine Gael)
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At 10.30 a.m. tomorrow.